1 Head injury

8/7/2019 1 Head injury

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Questions to askQuestions to ask

What is head injuryWhat is head injury

What are favorable factors in head injuryWhat are favorable factors in head injury

What are adverse factors in head injuryWhat are adverse factors in head injuryHow to diagnose a serious head injuryHow to diagnose a serious head injury

How to treat a serious head injuryHow to treat a serious head injury

Any other questions????Any other questions????


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Anatomical considerationsAnatomical considerations

The skull contains brain covered byThe skull contains brain covered by

meningesmeninges

80% of cranial cavity is occupied by brain80% of cranial cavity is occupied by brainMeninges: dura, arachnoid, and pia materMeninges: dura, arachnoid, and pia mater


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Anatomical considerationsAnatomical considerations

Cranial cavity is a closed cavityCranial cavity is a closed cavity

It has rigid, non resilient wallsIt has rigid, non resilient walls

Blood flow is autoregulatedBlood flow is autoregulatedBrain is a soft organBrain is a soft organ

The meningeal arteries run close to theThe meningeal arteries run close to the

bonesbonesThe brain is suspended in cerebrospinalThe brain is suspended in cerebrospinal

fluidfluid


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Physiological considerationsPhysiological considerations

Functions of brain: motor, sensory,Functions of brain: motor, sensory,

cognition, volition, and intellectualcognition, volition, and intellectual

functions.functions.Control of autonomic functionsControl of autonomic functions

Control of posture, coordination, andControl of posture, coordination, and

equilibriumequilibrium

Special senses smell, vision etc.Special senses smell, vision etc.


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Physiologic considerationsPhysiologic considerations

Brain; very busy organBrain; very busy organ

Consumes 20% of body oxygenConsumes 20% of body oxygen

Largest glucose userLargest glucose userNo time to store nutrients (busy organ)No time to store nutrients (busy organ)


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Head injuryHead injury

Blunt injuryBlunt injury

Penetrating injuryPenetrating injury


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Types of injuryTypes of injury

Coup injuryCoup injury

CounterCounter--coup injurycoup injury

Diffuse axonal injuryDiffuse axonal injuryFocal injuryFocal injury


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CLASSIFICATIONCLASSIFICATION

According to morphologyAccording to morphology

Scalp injuriesScalp injuries

Skull fracturesSkull fractures Intracranial injuriesIntracranial injuries

Diffuse neuronal injuryDiffuse neuronal injury

Hematoma: extradural, subdural, intracerebralHematoma: extradural, subdural, intracerebral

Primary brain injuryPrimary brain injury


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SCALP LACERATIONSSCALP LACERATIONS


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SCALP HEMATOMASCALP HEMATOMA

(The Raccoon Eyes)(The Raccoon Eyes)


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SCALP HEMATOMASCALP HEMATOMA

(The Raccoon Eyes)(The Raccoon Eyes)


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Assessment: GCSAssessment: GCS

GCS: Glasgow coma scoreGCS: Glasgow coma score

3 parameters:3 parameters:

Best eye responseBest eye response Best verbal responseBest verbal response

Best motor responseBest motor response

Max score 15Max score 15Min score 3Min score 3


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GLASGOW COMA SCOREGLASGOW COMA SCORE

Eyes openingEyes opening

SpontanousSpontanous 44

To verbal commandTo verbal command 33 To painTo pain 22

NoneNone 11


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Best verbal responseBest verbal response

OrientatedOrientated 55

ConfusedConfused 44 InappropriateInappropriate 33

IncomprehensibleIncomprehensible 22

NoneNone 11


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Best motor responseBest motor response

Obeys commandsObeys commands 66

Localises painLocalises pain 55 Withdrawal to painWithdrawal to pain 44

Flexion to painFlexion to pain 33

Extension to painExtension to pain 22

No motor responseNo motor response 11


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MAX POSSIBLE= E4+V5+M6=15MAX POSSIBLE= E4+V5+M6=15

MIN POSSIBLE= E1+V1+M1=3MIN POSSIBLE= E1+V1+M1=3


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SEVERITY OF HEAD INJURYSEVERITY OF HEAD INJURY

Mild: GCS=13Mild: GCS=13--1515

Moderate: GCS=8Moderate: GCS=8--1212

Severe: GCS=3Severe: GCS=3--77


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InvestigationsInvestigations

XX--ray skull AP & latray skull AP & lat

CT scanCT scan


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THE CT SCANTHE CT SCAN


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INVESTIGATIONSINVESTIGATIONS

XX--ray skullray skull

CT scanCT scan

ICP monitoring (intra cranial pressureICP monitoring (intra cranial pressuremonitoring)monitoring)


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ICP MONITORINGICP MONITORING


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ACUTE EXTRADURALACUTE EXTRADURAL

HEMATOMAHEMATOMASource: meningeal arteries esp middleSource: meningeal arteries esp middlemeningeal arterymeningeal artery

Diagnosis: clinical evaluation (lucidDiagnosis: clinical evaluation (lucidinterval), CT scan appearance (lenticularinterval), CT scan appearance (lenticular

mass)mass)

Treatment: evacuation by craniotomyTreatment: evacuation by craniotomy


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ACUTE SUBDURALACUTE SUBDURAL

HEMATOMAHEMATOMASource: cerebral veinsSource: cerebral veinsCommonest in occurrenceCommonest in occurrence

Diagnosis: clinical evaluation, CT scanDiagnosis: clinical evaluation, CT scanappearance (crescentic mass)appearance (crescentic mass)

Treated by evacuation through craniotomyTreated by evacuation through craniotomy


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ACUTE SUBDURALACUTE SUBDURAL

HEMATOMAHEMATOMA


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RAISED INTRACRANIALRAISED INTRACRANIAL

PRESSUREPRESSURESymptoms:Symptoms: Impaired level of conciousnessImpaired level of conciousness

HeadacheHeadache


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RAISED INTRACRANIALRAISED INTRACRANIAL

PRESSUREPRESSURESignsSigns Impaired level of consciousnessImpaired level of consciousness

Rising BPRising BP

Slowing pulseSlowing pulse

Slowing respirationSlowing respiration


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DIAGNOSIS OF RAISED ICPDIAGNOSIS OF RAISED ICP

Clinical evaluationClinical evaluation

ICP monitoringICP monitoring

X ray skull AP & latX ray skull AP & latCT scanCT scan


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MANAGEMENT OF RAISEDMANAGEMENT OF RAISED

ICPICPEvaluation and observationEvaluation and observationHyperventilationHyperventilation

OO22 inhalationinhalation

Treatment of mass lesionsTreatment of mass lesions (evacuation of(evacuation ofhematomas)hematomas)

Iv mannitolIv mannitol

Iv frusemideIv frusemideIv dexamethasone??Iv dexamethasone??


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A COMPREHENSIVE SCHEME OFA COMPREHENSIVE SCHEME OF

MANAGEMENT OF HEAD INJURYMANAGEMENT OF HEAD INJURY

The ATLS approach: the primary surveyThe ATLS approach: the primary survey

(ABCDE)(ABCDE)

AAirwayirway

BBreathingreathing

CCirculationirculation

DDysfunction of cnsysfunction of cns

EExposurexposure


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THE PRIMARY SURVEYTHE PRIMARY SURVEY

((AABCDE)BCDE)Airway:Airway: The finger sweepThe finger sweep

The jaw liftThe jaw lift


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((AABCDE)BCDE)The airway:The airway: The artificial airwayThe artificial airway


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(ABCDE)(ABCDE)The airwayThe airway The ambu bagThe ambu bag


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((AABCDE)BCDE)The airway:The airway: The artificial airwayThe artificial airway

LaryngoscopyLaryngoscopy


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((AABCDE)BCDE)The airway:The airway: Endotracheal intubationEndotracheal intubation


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((AABCDE)BCDE)Airway:Airway: CricothyroidotomyCricothyroidotomy


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((AABCDE)BCDE)The airway:The airway: TracheostomyTracheostomy


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TRACHEOSTOMYTRACHEOSTOMY


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(A(ABBCDE)CDE)Breathing:Breathing: Chest cageChest cage

PleuraPleura

Respiratory musclesRespiratory muscles


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(A(ABBCDE)CDE)


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(A(ABBCDE)CDE)


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(AB(ABCCDE)DE)CirculationCirculation

PulsePulse

Blood pressureBlood pressure

Central venous pressureCentral venous pressure

IV lines, CVP line, IV fluidsIV lines, CVP line, IV fluids

Volume replacement & hemodynamic stabilityVolume replacement & hemodynamic stability


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(ABCDE)(ABCDE)


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(ABCDE)(ABCDE)


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(ABC(ABCDDE)E)Dysfunction of cnsDysfunction of cns

AlertnessAlertness

Verbal responseVerbal response

PupilsPupils

GCS scoringGCS scoring-- baseline assessmentbaseline assessment


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MANAGEMENT OF HEADMANAGEMENT OF HEAD

INJURYINJURYAdmission to hospitalAdmission to hospital

Impaired conciousnessImpaired conciousness

History of unconciousnessHistory of unconciousness

Skull fractureSkull fracture

Children below 5yrsChildren below 5yrs

The drunk or intoxicatedThe drunk or intoxicated

Associated injuriesAssociated injuries


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Iv lineIv line

Ventilation and oVentilation and o22 inhalationinhalation

Imaging:Imaging:

X ray skull ap & latX ray skull ap & lat

X ray cervical spine ap & latX ray cervical spine ap & lat

Ct scanCt scan

The gcs scoringThe gcs scoring(Contd)(Contd)


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Management of raised ICPManagement of raised ICP

Definitive therapy e.g. Operation,Definitive therapy e.g. Operation,evacuation of hematomaevacuation of hematoma

Symptomatic treatmentSymptomatic treatment

RehabilitationRehabilitation


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Management of raised ICPManagement of raised ICP

Definitive therapy e.g. Operation,Definitive therapy e.g. Operation,evacuation of hematomaevacuation of hematoma

Symptomatic treatmentSymptomatic treatment

RehabilitationRehabilitation


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QuestionsQuestions to answerto answer

What is head injuryWhat is head injury

What are favorable factors in head injuryWhat are favorable factors in head injury

What are adverse factors in head injuryWhat are adverse factors in head injuryHow to diagnose a serious head injuryHow to diagnose a serious head injury

How to treat a serious head injuryHow to treat a serious head injury

Any other questions????Any other questions????


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Questions?Questions?

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1 Head injury